Background:

An effective patient care session involves excellent patient care, patient satisfaction, and physician and office staff wellness.  Achieving an effective care session, amidst the realities of patient complexity, limited patient visit times, and documentation and billing demands is challenging.  A balanced approach utilizing many different skills and techniques is needed to provide excellent care while still staying on-time and limiting the amount of after-hours work required.  

Objectives:

As a result of this activity, the residents will: 

  • Recognize a variety of techniques utilized by an experienced family doctor to manage a patient care session effectively

  • Synthesize their observations of the techniques recognized by reviewing them with a faculty coach to help apply them to their own patient care session management

 

Instructions:

Please review the questions in full before your shadowing experience.  Bring a copy of this guide with you to your assigned session.  A digital copy on your laptop is preferred (This will allow you to type notes and expand space for answers as needed.)  For the session, your objective is to observe the techniques used by your assigned attending family doctor to manage her/his patient care session effectively. The goal here is not to focus on medical knowledge, but to take this time to learn efficiency and style techniques. Your observations should be written down during and after each patient encounter; do not wait to record observations later.  Avoid talking to the doctor you are observing; instead, try to be a “fly on the wall,” so you can observe them in patient care mode only (undistracted by teaching).  [Their M.A./nurse will already have made the patient aware of your presence shadowing.]  If you have questions for the attending, please record them along the way.  At the end of the session, you will debrief with your assigned attending and can ask your questions then, as their time allows.   

 

Questions:

OVERALL SESSION QUESTIONS:

  1. What time did your attending start the session?  Finish with their last patient?

  2. Were they on-time/ahead/late overall?  How did they adjust their management based on whether they were running on schedule, ahead of schedule, or behind schedule?

  3. How did the attending document to keep up with their session and limit after-hours work?

PATIENT VISIT SPECIFIC QUESTIONS:  

4.  As much as you can tell by observing, what tasks were done before the patient arrived (pre-charting, pre-visit labs, MA huddle)?

5.  How did the attending utilize their support staff team to help with patient care?  What tasks did the MA complete before the provider entered the room (other than vitals, med-rec)?  During or after the provider’s initial visit with the patient?  

6.  How was the agenda set during different types of visits?

      1. New patient visit 

      2. Well Adult 

      3. Well Child 

      4. Chronic disease 

      5. Acute 

7.    How many problems were addressed at acute and chronic disease visits?

8. How were problems, if any, addressed at well visits?  (Were some deferred to a follow up or addressed only briefly, etc?)  

9. How was chart maintenance done?  

  • 1.    History

  • 2.    Problem list 

  • 3.    Medication list 

  • 4.    Health Maintenance/Care Gaps

  • 5.    Quality Indices (eg, PHQ2, etc)

10. What short cuts did you notice?  Smartphrases?  Dictation?  Shorter notes?  

11.  How were different types of challenging patients handled?  Were there any key phrases that you might adopt?  

  • 1.    Late patients

  • 2.    Talkative patients?  How did you observe the “art of interruption”? 

  • 3.    Difficult/demanding/argumentative/poor historian/etc patients?

12.  How did the provider keep track of time? How aware were they of their timing? 

13.   How was the visit ended? 

14. What tasks did the provider do after the patient left? 

15.  Was the note signed and encounter closed in real time? If not how was the end of the session handled regarding closing encounters? 

POST-SESSION QUESTIONS FOR THE ATTENDING:  (Briefly interview the attending at the end of the session using this guide.)

  1. How did you prepare for this session?  Did you pre-round?  If so, how much time did that take and how did you do it?  If not, why not?  (Some attendings may not pre-round as a purposeful choice.)

  2. How and when will you close your encounters from this session?  Why do you use the approach you use?

  3. Ask the attending if you can review a finished note or two from the session.  Are there any features of the note that stand out to you (It’s simplicity?  Tolerated imperfections like misspellings?  Areas of emphasis or areas surprisingly minimal?)  

  4. What are some of the key techniques you use that you think are most important for effective (including efficient) patient care sessions?

  5. What are some ways you protect yourself from excessive after-hours work or maintain wellness despite after-hours work?

POST-SESSION REFLECTION QUESTIONS:

  1. What techniques stood out to you the most?

  2. How would you have managed this session differently?  (Consider also, with those differences in approach recognized, which of those are stylistic/how-you-are-wired differences that you would not want to and don’t need to change, versus differences that you think you may need to adopt in order to adapt to the realities of the healthcare system.)

  3. How did the attending utilize their team (front office, MA, others) differently than you typically do?  

  4. What are some of the main areas and reasons you may have fallen behind in patient care that were mitigated by your attending’s techniques?